{"id":5053,"date":"2024-07-10T10:21:13","date_gmt":"2024-07-10T08:21:13","guid":{"rendered":"https:\/\/radiologie.aretis-staging.ch\/?page_id=5053"},"modified":"2025-03-06T09:35:28","modified_gmt":"2025-03-06T08:35:28","slug":"referrer-forms","status":"publish","type":"page","link":"https:\/\/radiologiezentrumbaden.ch\/en\/contact\/referrer-forms\/","title":{"rendered":"Referrer forms"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"5053\" class=\"elementor elementor-5053\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d8865c2 e-flex e-con-boxed e-con e-parent\" data-id=\"d8865c2\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-06ead83 e-con-full e-flex e-con e-child\" data-id=\"06ead83\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;none&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-496c1a9 elementor-widget elementor-widget-heading\" data-id=\"496c1a9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h5 class=\"elementor-heading-title elementor-size-default\">Registration online or via PDF<\/h5>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-dfd6036 elementor-widget elementor-widget-heading\" data-id=\"dfd6036\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Referrer - Forms<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8f506f3 e-flex e-con-boxed e-con e-parent\" data-id=\"8f506f3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-1ef4be3 e-flex e-con-boxed e-con e-child\" data-id=\"1ef4be3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-2d4c869 e-flex e-con-boxed e-con e-child\" data-id=\"2d4c869\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-077e346 elementor-widget elementor-widget-heading\" data-id=\"077e346\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Patient registration forms<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b67f366 elementor-widget elementor-widget-text-editor\" data-id=\"b67f366\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>The forms can be filled out directly on the computer. You can click on them or download them and fill them out directly.\u00a0<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-57006d0 e-con-full e-flex e-con e-child\" data-id=\"57006d0\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-a984a47 e-con-full e-flex e-con e-child\" data-id=\"a984a47\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6668425 elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"6668425\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/Anmeldung-NEU-14.2.25.pdf\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewbox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fca74e2 elementor-widget elementor-widget-icon-box\" data-id=\"fca74e2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/anmeldung_allgemein_fillable.pdf\" target=\"_blank\" >\n\t\t\t\t\t\t\tPatient registration (PDF)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tFillable PDF file\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6dbc5cd e-con-full e-flex e-con e-child\" data-id=\"6dbc5cd\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7eea16c elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"7eea16c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/Anmeldung-NEU-14.2.25.docx\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewbox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a2308f0 elementor-widget elementor-widget-icon-box\" data-id=\"a2308f0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/Anmeldung-allgemein.docx\" target=\"_blank\" >\n\t\t\t\t\t\t\tPatient registration (Word)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tFillable PDF file\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-8730f5d e-con-full e-flex e-con e-child\" data-id=\"8730f5d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-8d550c8 e-con-full e-flex e-con e-child\" data-id=\"8d550c8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fcea2a1 elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"fcea2a1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/CT-deutsch.pdf\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewbox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-31ac8da elementor-widget elementor-widget-icon-box\" data-id=\"31ac8da\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/ct_fragebogen_deutsch_fillable.pdf\" target=\"_blank\" >\n\t\t\t\t\t\t\tCT questionnaire (PDF)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tFillable PDF file\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2a452b5 e-con-full e-flex e-con e-child\" data-id=\"2a452b5\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-112a03b elementor-view-framed elementor-shape-square elementor-widget elementor-widget-icon\" data-id=\"112a03b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2025\/02\/MR-Fragebogen-Metarad-DEU.pdf\" target=\"_blank\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewbox=\"0 0 249.76 231.83\"><g transform=\"translate(-198.5 -144.43)\"><path d=\"m323.39 376.2c-23.46 0-46.91.14-70.36 0-25.77-.18-46.91-17.13-52.86-42.23a52.2 52.2 0 0 1 -1.55-11.3c-.19-13.46-.11-26.92-.06-40.38 0-6.36 3.21-10 8.5-10.06 5.56 0 8.54 3.37 8.56 9.89v37.89c0 22.88 16.17 39.22 39.19 39.3 39.75.12 79.51 0 119.26 0 7.48 0 15 .18 22.44-.29 19-1.2 34.36-17.54 34.59-36.61.15-13.29 0-26.59 0-39.88 0-6.85 3-10.4 8.66-10.33 5.4.06 8.39 3.59 8.4 10.1 0 13.46.09 26.92 0 40.38-.23 28.93-24.42 53.22-53.44 53.47-23.72.21-47.55.05-71.33.05z\"><\/path><path d=\"m331.77 290c15.66-15.65 30.1-30.1 44.55-44.53 5.93-5.93 10.92-6.81 14.91-2.67 3.74 3.88 2.72 8.87-3 14.58l-57.46 57.46c-5.13 5.14-9.44 5.28-14.5.23q-29.82-29.75-59.57-59.58c-4.08-4.1-4.43-9.24-1-12.8s8.7-3.24 13.11 1.15q20.85 20.75 41.63 41.57a32.83 32.83 0 0 1 3 4l1.67-.72v-5.55q0-64.29 0-128.57c0-7.22 3.05-10.58 9.11-10.13 4.43.32 6.94 2.83 7.46 7.2a45.32 45.32 0 0 1 .13 5.47v132.89z\"><\/path><\/g><\/svg>\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1b09c20 elementor-widget elementor-widget-icon-box\" data-id=\"1b09c20\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<a href=\"https:\/\/radiologiezentrumbaden.ch\/wp-content\/uploads\/2024\/09\/mr_fragebogen_ohne_schmerzdiagramm_metarad_fillable.pdf\" target=\"_blank\" >\n\t\t\t\t\t\t\tMRI questionnaire (PDF)\t\t\t\t\t\t<\/a>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tFillable PDF file\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-65d235a e-flex e-con-boxed e-con e-parent\" data-id=\"65d235a\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-5151b54 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"5151b54\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;fadeIn&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7dcd62c fluentform-widget-submit-button-custom elementor-widget elementor-widget-fluent-form-widget\" data-id=\"7dcd62c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"fluent-form-widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n            <div class=\"fluentform-widget-wrapper fluentform-widget-align-default\">\n\n            \n            <div class='fluentform ff-default fluentform_wrapper_4 ffs_default_wrap'><form data-form_id=\"4\" id=\"fluentform_4\" class=\"frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_4_1\" method=\"POST\" data-turnstile_key=\"0x4AAAAAAAjqZF2PnqEdqjr_\" action=\"\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Online registration<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='5053' \/><input type=\"hidden\" id=\"_fluentform_4_fluentformnonce\" name=\"_fluentform_4_fluentformnonce\" value=\"717ca2d39c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/5053\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_1\" ><h3>Personal details<\/h3><\/div><div data-type=\"name-element\" data-name=\"names\" class=\"ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_4_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"First name\" aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_4_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Surname\" aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Gender\">Gender<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_761df330747a74ea00de3394c20f24aa'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"weiblich\"  id='input_radio_761df330747a74ea00de3394c20f24aa' aria-label='female' aria-invalid='false' aria-required=\"false\"> <span>female<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_d403a5b307e325e22566d5075677e6d4'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"m\u00e4nnlich\"  id='input_radio_d403a5b307e325e22566d5075677e6d4' aria-label='Male' aria-invalid='false' aria-required=\"false\"> <span>Male<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text' id='label_ff_4_input_text' aria-label=\"Street\">Street<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" placeholder=\"Street\" data-name=\"input_text\" id=\"ff_4_input_text\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_1' id='label_ff_4_input_text_1' aria-label=\"Postcode\/location\">Postcode\/location<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" placeholder=\"Postcode\/location\" data-name=\"input_text_1\" id=\"ff_4_input_text_1\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_2' id='label_ff_4_input_text_2' aria-label=\"Date of birth\">Date of birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" placeholder=\"Date of birth\" data-name=\"input_text_2\" id=\"ff_4_input_text_2\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_3' id='label_ff_4_input_text_3' aria-label=\"Tel. private\">Tel. private<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" placeholder=\"Tel. private\" data-name=\"input_text_3\" id=\"ff_4_input_text_3\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_4' id='label_ff_4_input_text_4' aria-label=\"Mobile phone\">Mobile phone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" placeholder=\"Mobile phone\" data-name=\"input_text_4\" id=\"ff_4_input_text_4\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_5' id='label_ff_4_input_text_5' aria-label=\"Tel. business\">Tel. business<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" placeholder=\"Tel. business\" data-name=\"input_text_5\" id=\"ff_4_input_text_5\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Cost type\">Cost type<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_811a1918a803ab0afdf07ba2c9abe849'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Krankheit\"  id='input_radio_1_811a1918a803ab0afdf07ba2c9abe849' aria-label='Illness' aria-invalid='false' aria-required=\"false\"> <span>Illness<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_753b557dc20318f151c65d75dcc0a9b2'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Unfall\"  id='input_radio_1_753b557dc20318f151c65d75dcc0a9b2' aria-label='Accident' aria-invalid='false' aria-required=\"false\"> <span>Accident<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_8b00e1535066dfc74809776d2b88d4c1'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"IV\"  id='input_radio_1_8b00e1535066dfc74809776d2b88d4c1' aria-label='IV' aria-invalid='false' aria-required=\"false\"> <span>IV<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_5d9be9a5f452cc1db60925b8975cd78c'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"MV\"  id='input_radio_1_5d9be9a5f452cc1db60925b8975cd78c' aria-label='MV' aria-invalid='false' aria-required=\"false\"> <span>MV<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_7' id='label_ff_4_input_text_7' aria-label=\"Cost unit\">Cost unit<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" placeholder=\"Cost unit\" data-name=\"input_text_7\" id=\"ff_4_input_text_7\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_8' id='label_ff_4_input_text_8' aria-label=\"Insured person number\">Insured person number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" placeholder=\"Insured person number\" data-name=\"input_text_8\" id=\"ff_4_input_text_8\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_9' id='label_ff_4_input_text_9' aria-label=\"AHV number\">AHV number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" placeholder=\"AHV number\" data-name=\"input_text_9\" id=\"ff_4_input_text_9\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_2\" ><h3>Investigation<\/h3><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Investigation\">Investigation<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_a5157dabf1f15f6531295e396fdf33b1'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"MRT\"  id='input_radio_2_a5157dabf1f15f6531295e396fdf33b1' aria-label='MRI' aria-invalid='false' aria-required=\"false\"> <span>MRI<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_391829756c0d532a1c12c8086caac495'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"CT\"  id='input_radio_2_391829756c0d532a1c12c8086caac495' aria-label='CT' aria-invalid='false' aria-required=\"false\"> <span>CT<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_c1e1bd0214194744c6224c6c4d413dec'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Mammographie\"  id='input_radio_2_c1e1bd0214194744c6224c6c4d413dec' aria-label='Mammography' aria-invalid='false' aria-required=\"false\"> <span>Mammography<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_2356dfc1c8af435816c472257d4b87d4'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Ultraschall\"  id='input_radio_2_2356dfc1c8af435816c472257d4b87d4' aria-label='Ultrasound' aria-invalid='false' aria-required=\"false\"> <span>Ultrasound<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_0064008ed85fe36ac28fc654dda7472e'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"R\u00f6ntgen\"  id='input_radio_2_0064008ed85fe36ac28fc654dda7472e' aria-label='X-ray' aria-invalid='false' aria-required=\"false\"> <span>X-ray<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_1f427bf71e54ce60f81857e1c2d00d87'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Anderes\"  id='input_radio_2_1f427bf71e54ce60f81857e1c2d00d87' aria-label='Other' aria-invalid='false' aria-required=\"false\"> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_10' id='label_ff_4_input_text_10' aria-label=\"Region\">Region<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" placeholder=\"Region\" data-name=\"input_text_10\" id=\"ff_4_input_text_10\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description' id='label_ff_4_description' aria-label=\"Medical history\">Medical history<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description\" name=\"description\" id=\"ff_4_description\" class=\"ff-el-form-control\" placeholder=\"Medical history\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_1' id='label_ff_4_description_1' aria-label=\"Question\">Question<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_1\" name=\"description_1\" id=\"ff_4_description_1\" class=\"ff-el-form-control\" placeholder=\"Question\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-4_3\" ><h3>Referrer details<\/h3><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_11' id='label_ff_4_input_text_11' aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" placeholder=\"Date\" data-name=\"input_text_11\" id=\"ff_4_input_text_11\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_12' id='label_ff_4_input_text_12' aria-label=\"Doctor\">Doctor<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" placeholder=\"Doctor\" data-name=\"input_text_12\" id=\"ff_4_input_text_12\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_13' id='label_ff_4_input_text_13' aria-label=\"Practice\/Address\">Practice\/Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" placeholder=\"Practice\/Address\" data-name=\"input_text_13\" id=\"ff_4_input_text_13\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Date\">Date<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_b32047dbac1e48a06b6a3fb67469178e'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Patient aufbieten\"  id='input_radio_3_b32047dbac1e48a06b6a3fb67469178e' aria-label='Call up patient' aria-invalid='false' aria-required=\"false\"> <span>Call up patient<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_dd7190b4d1b6783710c8a8fe4f694a85'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Patient hat Termin\"  id='input_radio_3_dd7190b4d1b6783710c8a8fe4f694a85' aria-label='Patient has an appointment' aria-invalid='false' aria-required=\"false\"> <span>Patient has an appointment<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_2' id='label_ff_4_description_2' aria-label=\"Remarks\">Remarks<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_2\" name=\"description_2\" id=\"ff_4_description_2\" class=\"ff-el-form-control\" placeholder=\"Remarks\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_description_3' id='label_ff_4_description_3' aria-label=\"Send a copy of the findings:\">Send a copy of the findings:<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_4_description_3\" name=\"description_3\" id=\"ff_4_description_3\" class=\"ff-el-form-control\" placeholder=\"Send a copy of the findings:\" rows=\"3\" cols=\"2\" data-name=\"description_3\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-el-form-hide_label  ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Transmission\">Transmission<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_89bbcd9b01cd136bd068c322e535c936'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"via Uploadlink\"  id='input_radio_4_89bbcd9b01cd136bd068c322e535c936' aria-label='via upload link' aria-invalid='false' aria-required=\"false\"> <span>via upload link<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_314595d092d7a5ae9c508cfcd98b7e8e'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"E-Mail\"  id='input_radio_4_314595d092d7a5ae9c508cfcd98b7e8e' aria-label='e-mail' aria-invalid='false' aria-required=\"false\"> <span>e-mail<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_555cb7cd7d2ea38cc8e88396dad72dd2'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"telefonisch\"  id='input_radio_4_555cb7cd7d2ea38cc8e88396dad72dd2' aria-label='by telephone' aria-invalid='false' aria-required=\"false\"> <span>by telephone<\/span><\/label><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_email' id='label_ff_4_email' aria-label=\"e-mail\">e-mail<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_4_email\" class=\"ff-el-form-control\" placeholder=\"e-mail\" data-name=\"email\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group ff-el-form-hide_label'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_4_input_text_14' id='label_ff_4_input_text_14' aria-label=\"Telephone\">Telephone<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" 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